MEDICARE: COUNSELING BEYOND BORDERS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1952923856
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNSELING BEYOND BORDERS LLC

Provider Business Mailing Address
First Line	:	22430 GRATIOT AVE UNIT 620
Second Line	:
City	:	EASTPOINTE
State	:	MI
Zip	:	48021-7022
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4221 MORAN ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-1705
Country	:	US
Telephone Number	:	313-908-8111
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TANYA RO SHUN BANKSTON
Credential	:	LLPC
Telephone Number	:	313-908-8111

Provider Enumeration Date	:	05/13/2020
Last Update Date	:	05/13/2020

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